Assessing efforts towards universal financial risk protection in low- and middle-income countries

Universal financial risk protection through social health insurance: The Costa Rican Health System and the role of the Government ID Number

Costa Rica, still a poor country at its centennial anniversary in 1921, slowly created a Universal Coverage health care system in the twentieth century. Little is known of how it came about and the public policy features of the process have not been adequately studied. This study will contribute to the advancement of knowledge on universal coverage by spelling out the process, the politics, and the various shades of success.

This project addresses the question of how Costa Rica achieved universal coverage as a relatively poor country, and how it has since sustained the coverage. The study is ultimately a work of policy analysis, using multiple research techniques, including quantitative and qualitative analysis along with a case study.

The three health financing functions of the Costa Rican health financing scheme will be explicitly addressed. The study includes an analysis of the changes ushered in by the 1990s health sector reform, the health care provision network and the question of its role on the achievements of Costa Rica’s health system. The qualitative policy analysis tools will show how the system design yielded the process, content, context and stakeholder dynamics that made universal coverage possible. How that process was accompanied by, and at times adjusted for Costa Rican society, will be a significant “value add” of this study. The limited writing available on these subjects is recognized and it could also be a significant input for policy-makers and stakeholders in other countries.

Research objectives

• To complete a case study of the Costa Rican health system with a focus on its achievements and challenges in terms of financial risk protection and equity in access to health care, following the Carrin and James (2004) and Carrin et al. (2008) framework:
• To evaluate the design and performance of the health financing system (revenue collection, pooling, purchasing);
• To evaluate the design and performance of the health care provision network in view of equity in access;
• To sort out the main factors, both exogenous and endogenous to the health system, that explain how Costa Rica constructed universal coverage in health, and how it has managed to sustain it;
• To analyse the political context in which the system developed, with a focus on the elements that are key to financial risk protection and equity in health;
• To identify the main policy and institutional actors and to understand their role in the development of the system (policy products and actors);
• To explore the policy implementation process;
• To understand the political and financial sustainability of the policy in the medium term.

Given the relative success of the Costa Rican NHS, the study will help policy-makers and stakeholders to positively affect their own health care strategies, their health systems development, and the shape of their health policies. The chief outputs of the project will be: a paper about the historical context of the evolution of the NHS; a health financing analysis of revenue collection, pooling and purchasing; a paper about equity in access; a paper about the level of responsiveness by two different management systems; a case study on policy analysis of the implementation of revenue collection, pooling and purchasing; and a paper about the challenges of the Costa Rica health system in terms of financial and political sustainability.


Project description

Programme: Assessing efforts towards universal financial risk protection in low- and middle-income countries

Research title: Universal financial risk protection through social health insurance: The Costa Rican Health System and the role of the Government ID Number

Thematic Research Area: Health Financing

Grantee Country: Costa Rica

Grantee Institution: Universidad de Costa Rica

Programme coordinator: Juan Rafael Vargas

Start date: September 2010

Status of grant: Completed

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